Provider Demographics
NPI:1508048083
Name:WIELAND, JENNIFER KAY
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:KAY
Last Name:WIELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82074
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-2074
Mailing Address - Country:US
Mailing Address - Phone:907-455-9737
Mailing Address - Fax:
Practice Address - Street 1:615 23RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7041
Practice Address - Country:US
Practice Address - Phone:907-455-9737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM4583Medicaid